April 25, 2007
Volume 9, Issue 9
Midwifery Today E-News
“Waterbirth”
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In This Week’s Issue:


Quote of the Week

"I take the dolphin approach. Dolphins have a midwife in attendance at their births, breastfeed for about two years, birth all their babies in water and have been doing this longer than humans. After a dolphin birth, either the mother or the midwife, in a fluid movement, brings the baby up to the surface for the first breath."

Marina Alzugaray


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The Art of Midwifery

Water is a soothing medium that many women use to ease the pain of childbirth.

The benefits of using a pool include ease of mobility, less risk of tearing and an opportunity for a drug-free birth. Water can help the body produce its own pain-relieving hormones, can relax one's inhibitions, conserve energy, give pain relief, lower blood pressure and lessen pressure on the abdominal muscles.

Kirsten Millinson
excerpted from "Home Waterbirth in England," Midwifery Today Issue 52


Midwifery Today Issue 61 has instructions on making your own waterbirth tub.

ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.


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Waterbirth Recommendations

The main recommendations are based on the fact that immersion in water at the temperature of the body tends to facilitate the birth process during a limited length of time (in the region of an hour or two). This simple fact is confirmed by clinical observation and by the results of a Swedish randomised controlled study suggesting that women who enter the bath at five centimetres or after ("late bath group") have a short labour and a reduced need for oxytocin administration and epidural analgesia. Physiologists can offer interpretations. The common response to immersion is a redistribution of blood volume (more blood in the chest) that stimulates the release by specialized heart cells of the atrial natriuretic peptide (ANP). The inhibitory effect of ANP on the activity of the posterior pituitary gland is slow, in the region of one to two hours. When a woman is in labour this inhibitory effect is preceded by an analgesic effect that is associated with lower levels of stress hormones and increased release of oxytocin. Furthermore it is partly via a release of oxytocin that the redistribution of blood volume stimulates the specialized heart cells.

The first practical recommendation is to give great importance to the time when the laboring woman enters the pool. Experienced midwives have many tricks at their disposal to help women be patient enough so that they can ideally wait until five centimetres dilation. A shower, which more often as not implies complete privacy, is an example of what the midwife can suggest while waiting. The British Medical Journal survey clearly indicates that many women stay too long in the bath (the average time was in the region of three hours for women who gave birth in water!). One reason is that many of them enter the bath long before five centimetres.

The second recommendation is to avoid planning a birth under water. When a woman has planned a birth under water she may be the prisoner of her project; she is tempted to stay in the bath while the contractions are getting weaker, with the risk of long second and third stages. There are no such risks when a birth under water follows a short series of irresistible contractions.

The recommendations regarding the temperature should not be overlooked. It is easy to check that the water temperature is never above 37 degrees C (the temperature of the maternal body). Two cases of neonatal deaths have been reported after immersion during labor in prolonged hot baths (39.7 degrees C in one case). The proposed interpretation was that the fetuses had reached high temperatures (the temperature of a fetus is 1 degree higher than the maternal temperature) and could not meet their increased needs in oxygen. The fetus has a problem of heat elimination.

At the dawn of a new phase in the history of childbirth one can anticipate that, if a small number of simple recommendations are taken into account, the use of water during labor will seriously compete with epidural anesthesia. Then helping women to be patient enough and enter the pool at the right time will appear as a new aspect of the art of midwifery.

Michel Odent
excerpted from "A Landmark in the History of Birthing Pools"
Midwifery Today Issue 54


Read more articles about waterbirth in Midwifery Today Issue 54. Order your copy here.


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Research to Remember

Perinatal mortality is not substantially higher among babies delivered in water than among those born to low risk women who delivered conventionally.

British Medical Journal 319: 483–87, 1999


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In the last 10 years, water-assisted labor has grown exponentially. In 1995, there were only three hospitals in the country that offered it. Now it is offered in more than 260 hospitals—15% of all US hospitals. In [2005] alone there was a 4% increase, and this number is expected to grow in the coming year.

Sheri Menelli
Top Trends in Pregnancy and Birth, www.prweb.com/printer.php?prid=341223


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Question of the Week

Q: I have just received a kidney transplant and it seems as though the positive messages I got before the transplant about pregnancy being pretty normal and fairly easy have been replaced with warnings that extend beyond the first year when the immunosuppression is most severe. I would appreciate hearing from midwives who have attended births of women with kidney (or other abdominal organ) transplants. What common problems or complications arise and what kinds of remedies/preventive intervention can be used to address them?

— Adria Armbrister, New York, New York


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


Question of the Week Responses

Q: What are the possible damages that can be caused by using IUD as a birth control method?

— Bella

A: Intra-uterine devices (IUDs) prevent pregnancy via a number of mechanisms, including inhibition of sperm function, stimulation of inflammatory response, which destroys the ovum, or prevention of implantation of an early embryo if conception occurs.(1) The post-fertilization effects of IUDs may be unacceptable to many users.(2)

IUDs fail to prevent pregnancy at a rate of approximately 3% in the first year of use.(3) Failure of the IUD is frequently related to expulsion or other dislocation of the device (4), often requiring surgical removal.(5) Common reasons for removal of the devices include insertion pain (6), failure to prevent pregnancy, excessive bleeding, post-insertion pain and pelvic inflammatory disease.(7) IUD use may also affect future fertility, as one study showed an increased rate of tubal occlusions in previous IUD users.(8) There is a very high rate of complications for devices inserted in the immediate post-placental period (40.4%) and early postpartum period (74.4%), compared to 19.2% when insertion is done at some other time.(9)

If pregnancy does occur while the IUD is in place, the device may endanger the pregnancy and higher-than-average rates of miscarriage and premature delivery occur in pregnancies in which an IUD is present in the uterus.(10) Surgical removal is often, though not always, necessary.(11)

References:

  1. GRMA News 1993. How do I.U.C.D.s prevent pregnancies? (Answer to Question). 10.
  2. Dye, H.M., et al. 2005. Women and postfertilization effect of birth control: Consistency of beliefs, intentions and reported use. BMC Womens Health, 28, 11.
  3. Eroglu, K., et al. 2006. Comparison of efficacy and complication of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year followup. Contraception, 74, 376–81; Thonneau, P., et al. 2006. Risk factors for IUS failure: Results of a large multicentre case-control study. Human Reproduction, 21, 2612–16.
  4. Inal, M.M., K. Ertopcu and I. Ozelmas. 2005. The evaluation of 318 intrauterine pregnancy cases with an intrauterine device. European Journal of Contraceptive and Reproductive Health Care, 10, 266–71; Merki-Feld, G. S., et al. 2007. Partial and complete expulsion of the Multiload 375 IUD and levonorgesterel-releasing IUD after correct insertion. European Journal of Obstetrics, Gynecology and Reproductive Biology, E-publication ahead of print.
  5. Ozgun, M.T., et al. 2007. Surgical management of intra-abdominal mislocated intrauterine devices. Contraception, 75, 96–100.
  6. Grimes, D.A., et al. 2006. Non-steroidal anti-inflammatory drugs for heavy bleeding or pain associated with intrauterine-device use. Cochrane Database of Systematic Reviews, 18, CD06034.
  7. Haugan, T., et al. 2007. A randomized trial on the clinical performance of Nova T380 and Gyne T380 Slimline copper IUDs. Contraception, 75, 171–76.
  8. Merki-Feld, G.S., et al. 2007. Tubal pathology: The role of hormonal contraception, intrauterine device use and Chlamydia trachomatis infection. Gynecologic and Obstetric Investigation, 63, 114–20.
  9. Eroglu, et al.
  10. Inal, M.M., S. Koetsawang, D. Rachawat and M. Piya-Anant. 1977. Outcome of pregnancy in the presence of intrauterine device. Acta Obstetricia et Gynecologica Scandinavica, 56, 479–82.
  11. Sviggum, O., F.E. Skjeldestad and J.M. Tuveg. 1991. Ultrasonically guided retrieval of occult IUD in early pregnancy. Acta Obstetricia et Gynecologica Scandinavica, 70, 355–57.

— Petra Bradley

A: Though there are many risks with most forms of birth control, the IUD poses risks not associated so strongly with other methods.

The risk of ectopic pregnancy is increased substantially with the copper IUDs such as ParaGard. Because this IUD creates an unsuitable uterine environment for implantation, a tubal or para-cervical pregnancy becomes more likely than without the IUD in place. Both of these conditions can be life-threatening if not detected early. Some early warning signs may be missed by the user because the intense cramping and discomfort may be attributed to the IUD itself rather than a possible problem.

Another concern is the possibility of pregnancy in general. An IUD user may not realize early on that she has become pregnant or may deny the fact because she feels protected. This could lead to problems for a pregnancy that may in fact be viable. The longer an IUD is in place during a pregnancy, the more likely it is that the IUD will cause a physical problem for the baby. IUDs left in place throughout pregnancy have been found to migrate into the structure of the baby or to cause serious deformities. Having the IUD in place may also increase the risk of mid- to late-term spontaneous abortion. This is not always the case. I'd like to share my story with you.

In January 2005 my husband and I decided we might like to have another baby. I called and made an appointment to have my ParaGard IUD removed. Just after making the call I sat down at the computer and began charting my last few menstrual cycles to try and figure out when would be a good time to try to conceive. Our time schedule was a bit limited by my husband's impending deployment to Iraq, just eight months away. During this charting I realized that my cycle was late by almost a full week. For someone who has a clockwork cycle, it was ODD! I brushed it off; we had been traveling, had some financial issues and Eric had just returned after being away for 12 weeks; all the stress had to have been plenty to throw off my cycle! Four days later I woke at 6 am. I was happy, which is an oddity for me; I am NOT a morning person unless I have to be. I knew something wasn't right. I purchased a urine HCG test at the grocery store and hubby and I hovered in the bathroom watching the control window. We didn't have long to wait; the second line appeared instantly. It wasn't faint or hard to read, it was PINK! I was almost panicked! It was a holiday weekend and I knew I would be unable to see the doctor until Tuesday. I spent the next few days feeling nervous and anxious!!

I finally was able to see the doctor and spent all day being bounced from provider to provider, from the lab to the exam room. No one could believe that I was pregnant with an IUD; it just doesn't happen, they said! Late in the afternoon the head of our OB/GYN floor was out of surgery and able to see me. He insisted that I had either expelled the IUD and missed it, or that it had migrated through the uterine wall and that was how I became pregnant. After a quick exam my IUD was determined to be in place. The ultrasound confirmed that it was just as it should be, and just above it was a gestational sack. The sac was snuggled tight to the top of my uterus in a small pocket unfilled by the IUD. We made the decision to remove the IUD knowing that the risk of miscarriage was high. The doctor reassured us that he didn't think the removal would disturb the pregnancy at all and as long as the cramping of the uterus following the removal was minimal, he thought the pregnancy would be viable.

I returned a week later for another ultrasound. This time we had a heartbeat! The remainder of my pregnancy was as simple and routine as they come. I changed providers once we were sure all was well. Eighteen months ago I delivered my "miracle baby" at home into the arms of a loving CPM. She was 9 lb 8 oz of chubby, pink, happy baby! Today she is an active toddler with no sign or symptom of her perilous start!

— Kari Pollack
Midwifery Student/Doula

A: I have had two IUDs in the last 10 years. My first one somehow became imbedded in my uterus, which I was told could cause possible scarring and could inhibit my ability to become pregnant. It caused intense pain and the removal process was pretty bad—though I did not have any residual problems and conceived a healthy baby only a few short months later. Regardless of my negative experience, I so enjoyed the freedom that the IUD provided, that after having my baby I decided to get another one. I've had it over four years and love it. I experienced only minor discomfort at insertion, cramping for a few weeks subsequently and have had no problems what so ever since. My experience is that the risk-to-benefit ratio leans towards that absolute benefit of IUDs. I think they are incredible!

— Andrea Huddleston
Alpine, Utah

A: I provide a full array of contraceptive options in my practice, including IUD insertion. One of the best summaries of IUDs that I have seen is an American College of Obstetricians and Gynecologists (ACOG) publication—not usually my first source of information, but this practice bulletin is really good and comes with three pages of references. I give a copy to anyone considering getting an IUD. So, as to info on IUDs (including risks of each type, studies, etc.): ACOG Practice Bulletin, Clinical Management Guidelines for Obstetricians-Gynecologists, Number 59, January 2005. As far as "damages," a chart in the publication shows that the uterine perforation rate was 0.1% for the Mirena and 0 for the ParaGard (this risk appears to decrease with increased experience of the person performing the insertion). The rate of pelvic inflammatory disease was 0.7% for each, and is highest in the first month following insertion. The pregnancy rate was 0.2% for the Mirena and 0.3% with the ParaGard; however, if pregnancy does occur, it is more likely to be ectopic. Putting these numbers together, the ectopic pregnancy rate is less than 0.5 per 1000 woman-years for IUD users, versus 3.25-5.25 per 1000 for women not using contraception. Hope this answers your question.

— Hilary Schlinger, CNM, CPM
Albuquerque, New Mexico

A: The IUD fell out of wide usage in the US in the 1970s when one type of IUD, the Dalkon Shield, was linked to infections. It was removed from the market over 25 years ago. The IUD is the most widely used contraceptive in the world now, and while in other countries there are several different types to choose from, in the US there are only two, the ParaGard and the Mirena. In most countries the midwives insert IUDs, which takes generally 5 minutes or so. They last 5–12 years, depending on the type of IUD.

IUDs do not act as a monthly abortion. In studies, women whose hCG levels were checked weekly never had a rise, indicating that women with IUDs never became pregnant.

The leading side effect of using a copper IUD such as ParaGard is heavy menstrual bleeding. The LNG IUD, sold under the trade name of Mirena, is not copper and releases progestin to reduce uterine bleeding. Twenty percent of women with a Mirena will have no monthly bleeding. This is why the Mirena, rather than a hysterectomy, is used to control heavy uterine bleeding.

Actual complications of the IUD are uncommon, but can include embedding in the uterine wall, which may require surgery for removal. They also may be expelled.

A woman with multiple sex partners should not have an IUD. This is because some sexually-transmitted diseases can spread into the uterus and rest of the body more quickly when an IUD is in place, leading to sterility or serious systemic infection.

— Camellia May
Houston, Texas


Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


Think about It

I am currently pregnant with my sixth child (my fifth was a photo album print in a past Midwifery Today issue). I had "all day morning sickness" which has just recently subsided. My eleven-year-old daughter, who has been at all her siblings' homebirths, enlightened me with this exchange: "Well, how pregnant are you?" (I'm just into my second semester.) "Well then it makes sense that your morning sickness is starting to be over, you are no longer in the morning of your pregnancy."

It would seem that she compares the trimesters of pregnancy to times of day!

I thought it was quite insightful for an eleven year old. Thanks for letting me share.

Pam Embler


Feedback

SEEKING FOOD WISDOM: For a book on the ideal diet for conception, pregnancy and nursing, and ideal first foods for babies on weaning, I am seeking information about traditional, i.e., pre-industrial, diets. For example, in Fiji and the Swiss Alps, traditional foods for fertility were crab and butter from grass-fed cows. In Lebanon, a first food is lamb; in Italy, Parmigiano with olive oil. Write info@NinaPlanck.com with family memories or published studies on diet-related implications for health of mother, father and baby.

Nina Planck
www.NinaPlanck.com


International Day of the Midwife celebrating in UK on 4th May

I am writing from Guildford Royal Surrey County Hospital, UK, to enquire whether you have any specific data and literature on midwifery in developing countries: we are mounting a display for our celebration day here at this hospital and are including Malawi, Ghana, Cambodia, but would like more on needy countries to give an insight into how most of the midwifery world struggles (Iraq particularly comes to mind now but there are so many needy countries). Do you have any links to downloads on the main hardest hit areas, stats and posters or printouts? We would be very grateful. Here are details of our own situation and plans for the day/week.

Midwifery Week/International Day of the Midwife: Friday 4th May 2007, 10 am to 5 pm
Antenatal Clinic, Level B, Royal Surrey County Hospital, Guildford, Surrey UK

We are planning a Celebration Day for midwives at the Royal Surrey County Hospital and are inviting associated groups, therapists, mums and babies, members of the press, so as to highlight the important work performed continuously by midwives and other teams to bring babies into the world safely, with love and support to give them the best start in life.

There will be an exhibition of sponsors, therapies and products in the Ante Natal Clinic. On this special day we will also be commemorating the work of midwives in Third World developing countries, whose task is made more difficult by a lack of resources and facilities, as well as training. See World Health Organization: http://www.who.int/making_pregnancy_safer/news/international_midwives_day/en/

Jolande Murray (for Jenny Hughes, Head of Midwifery and Maternity Services)
PA to Head of Maternity Services
Royal Surrey County Hospital, Guildford, Surrey GU2 7XX
Direct Tel: 01483 406725; Internal ext: 4704 Fax: 01483 564584
E-mail: jolande.murray@royalsurrey.nhs.uk


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